Authors

Drugs Used to Treat HIV Have Become Targets for Fraud Investigations

  • Cindy Gallee, JD, RHIA, CHC
  • Aug 29, 2014
  • Comments

Antiretroviral drugs, used to treat Human Immunodeficiency Virus (HIV), have recently come under scrutiny by the Office of Inspector General (OIG) as a target for fraud, waste and abuse. According to the World Health Organization, in the year 2013 there were approximately 35 million people living with HIV, and an estimated 12 million HIV patients undergoing treatment with antiretroviral therapy. Antiretroviral drugs were first used to treat HIV in 1987, and today there are approximately 30 ap ...

Detect FWA Using Patterns in Procedure & Diagnosis Code Pairings

  • Cindy Gallee, JD, RHIA, CHC
  • Aug 15, 2014
  • Comments

Payers can detect fraudulent billing schemes by analyzing certain CPT codes that are used in conjunction with ICD diagnosis codes and determining aberrant patterns , such as: a provider who bills a certain CPT code with the same diagnosis every time; a provider billing a certain CPT code with a diagnosis that does not support medical necessity; or an illogical number of a certain procedure billed within a time frame. An aberrant pattern, though not always fraudulent, can be investigated and th ...

Tips for Payers to Improve Monitoring Hospital Admissions for Fraud

  • Cindy Gallee, JD, RHIA, CHC
  • Aug 11, 2014
  • Comments

On August 4, 2014, the Department of Justice announced a settlement with Community Health Systems, Inc. (CHS) for $98.15 million to satisfy allegations CHS improperly billed Medicare, Medicaid and Tricare for inpatient admissions that should have been billed as outpatient or observation services. CHS is the largest operator of acute care hospitals in the country, which currently number 206 hospitals in 29 states. The lawsuit specifically alleges that CHS, through corporate policy, encouraged in ...

4 Ways for Payers to Detect Fraudulent Therapy Services

  • Cindy Gallee, JD, RHIA, CHC
  • Jul 23, 2014
  • Comments

In a July 2014 news release, the Department of Justice announced the guilty plea of a Florida podiatrist to one count of  healthcare fraud for billing Medicare falsely for Micro-vas treatments. At issue were the podiatrist’s claims to Medicare for therapy services that were non-covered, were incorrectly coded as physical therapy, and were coded as the doctor performing the service when he had not. Micro-Vas is a trademarked device that provides deep penetrating electrical stimulatio ...

The High Cost of Spinal Surgery - Necessary or Potential Fraud?

  • Cindy Gallee, JD, RHIA, CHC
  • Jul 21, 2014
  • Comments

The number of spinal surgeries done in the U.S. has increased in a recent 10 year period by 137%. And the national bill for those surgeries has increased by almost 8 times. This trend has not gone unnoticed by payers.   Lumbar spinal fusion surgeries in particular have been focused on as a target for cost savings. There are conflicting reports as to whether these surgeries are always necessary, whether less invasive therapies can be employed before resorting to surgery, or whether spinal ...

Subscribe to Our Blog:

Connect With Us

Authors

Posts by Topic


Proudly Affiliated with:

Proud_Members_Logo_250X100Affiliate with FedRAMP and AWSNational Association of Dental Plans Member